Laserfiche WebLink
�+ C <br /> o San Joaquin County <br /> 2' z Environmental Health.Department SITE <br /> N' 600 East Main Street, Stockton,CA 95202-3029 MITIGATION <br /> • (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is herrt"ade to San Joaquin County for permit to Construct and/or Install the work described. This Application is made tri Compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquln County Environ ental Health Department. <br /> _ lrt f C� Assessors ✓� 0 <br /> WELL LacatEort�7J-�}� LA� _ � Cross Street City Zip <br /> PROPER�rLo ��)Phone# <br /> owner r^�nur�t�SdG�S�e+��+IAJfAddress i�5�s�`[ G.; }{ )�-- city1 ZI <br /> , <br /> C-57ContractorTlll (J�(A1�!�'Y]-j. Address ��[{�-.,tf�rsdrl n if Gity l�fUi�`, Zlp I�LIc#DI�� ,Phbn # �U a_13 `1 <br /> Consultant/Sub Cntr /ff Address of �i!%tuW t City _LIc# 'Phone# r/ <br /> GIS Coordinates:X .3�•���3 Y~1V-I• V�5 Township Range Section <br /> WORK TO BE PERFORMED: <br /> U NEW WELL I BORING (CPT.GEOPROBE,HYBROPUNCH,HAND-AUGER,OTHER`) *ESTRUCTION <br /> (choose type bolow) <br /> o SOIL BORING# DIAMETER. <br /> 3-S`- _ <br /> .Q WELL# RESSURE GROUT O <br /> Other `` GOUT SPECIFICATION <br /> COMMENTS: Akr Or! 1 - 4- V,/ t <br /> TYPE OF WE l INSTALLATION TYPE CONSTRUCTIONSEECIFICATIONS <br /> a MONITORING a HOLLOW STEM -DIA.OF BOREHOLE, Q.MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:-- <br /> U.EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: n STEEL .©PVC a OTHER: <br /> a VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: n AUGERS ©HOSE <br /> p AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER: n OTHER - ' APPROX.BORING DEPTH- a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR;INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the.work will be done In accordance with San Joaquin �y v <br /> County Ordinances, Rules and Re Mations,and all applicable California State Laws. <br /> } /�1 �/_,� <br /> Signed x Title/Company�rV lam, J a4 aC (�U10-)T54- .7_t`'.�__ <br /> Print Name (' G J.62 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: .l3 a 9 /-,_„_/,f/r 2, C <br /> WORK PLAN DATED: L <br /> Application Accepted By .Date Issued . Area, 4O <br /> Grout Inspection By aFinal Inspection�'�"""”" ISate 7i Z %U <br /> Destruction Inspection B Date / <br /> COMMENTS I CONDITIONS: . . <br /> ACCOUNTING ONLY: AID# FAQ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK i* RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE. <br /> C-57 WC -WAIVER C-57tetter of Authorization to sign permit!_.-Encroachment doc 'd <br /> EHD29-02-001 WEB <br /> 9/1112007 <br />